The Practice incorrectly initially referred Mrs X to dermatology
25. Mrs X says in April 2023, the Practice incorrectly referred her for a dermatology appointment to investigate the skin tag on her vulva. In May 2023, the dermatologist said they were unable to remove her skin tag as they are benign (non-cancerous) and not treated on the NHS. Mrs X feels the referral was pointless and the Practice should have referred her to a gynaecologist instead. She says she did not get referred until July 2023. In this time, her skin tag had grown and become more uncomfortable.
26. We recognise it would have been disappointing and frustrating for Mrs X when she was told she could not undergo treatment with the dermatologist in May 2023. We are sorry to hear her pain got worse and that this was impacting her quality of life.
27. We asked our GP adviser to tell us whether the dermatology referral in April 2023 was appropriate in the circumstances.
28. GMC guidelines explain clinicians should ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’ and refer a patient to another practitioner when this serves the patient’s needs’.
29. The records show Mrs X’s GP suspected she had a skin tag on her vulva in April 2023. In December 2023, a private clinic confirmed it was a Vulval Intraepithelial Neoplasia 3 (VIN). A VIN is when abnormal cells develop in the top layer of skin covering the vulva. It is not vulval cancer, but the abnormal cells could turn into cancer. The cancer research UK guidelines explain when a patient has a suspected VIN, they should be referred to either a dermatologist or gynaecologist for more investigations.
30. In this case, our GP adviser confirmed Mrs X’s GP promptly gave ‘suitable advice’ and referred Mrs X to an appropriate practitioner to ‘serve her needs’. The records show in April 2023, the GP referred her to a dermatologist. This was to investigate and confirm a diagnosis of the skin tag.
31. Importantly, the cancer research guidelines say patients should be referred to a dermatologist or gynaecologist when the patient has a suspected VIN. That said, we can see the Practice’s decision to refer her to a dermatologist was appropriate in the first instance. This is the usual route for the treatment of skin lesions, and it is the appropriate route to investigate suspected VINs.
32. Our GP adviser added even if the Practice had identified and confirmed on sight Mrs X’s lump was VIN3, it would have been correct to refer her either to a dermatologist or gynaecologist to confirm this. This is because they are the ‘appropriate practitioner’ with the relevant expertise to confirm this diagnosis.
33. We recognise it will have been worrying for Mrs X to feel her care was delayed. We would like to reassure her the Practice followed appropriate guidelines and correctly initially referred her to a dermatologist to assess her skin tag. We did not see indications of failings for this part of the complaint.
The Practice should have identified that Mrs X’s lump was potentially VIN and put the referral through as urgent rather than routine
34. Mrs X says the Practice should have confirmed the lump on her vulva was a VIN3 in her first appointment. She also says it should have placed an urgent gynaecology referral for her rather than a routine one. This left her feeling distressed and anxious that her VIN3 could have developed into cancer whilst she was on the waiting list.
35. We do not wish to underestimate how worrying it must have been for Mrs X whilst she was waiting for her appointment. Understandably, her health is very important to her, and it would have been incredibly difficult waiting for further specialist treatment.
36. GMC guidelines explain clinicians have a duty to ‘provide good clinical care’. It states when treating a patient, they should take steps to ‘adequately assess the patient’s condition’ including their symptoms and clinical history.
37. The VIN guidance explains the usual features of a VIN. It states when a patient has a VIN it may appear as one or more ‘flat or slightly raised, well defined or irregular skin lesions that may be pink, red, brown or white.’
38. The cancer research guidelines also outlines further symptoms of VIN. It says patients may experience itching, changes to the vulval skin and discomfort or pain during sex.
39. NHS Health A to Z guidelines explain skin tags are ‘soft, skin-coloured growths on the skin. They are very common and usually harmless’. It also states ‘skin tags do not need to be removed, but if they're causing problems they can be removed’.
40. The records show in April 2023, the Practice’s GP assessed the lump on Mrs X’s vulva and considered her clinical history. The outcome was the lump did not have the usual features of a VIN. Instead, it had the appearance of a skin tag. Further, when Mrs X attended the Practice, she did not report any of the associated symptoms of a VIN. The records indicate she told the GP she noticed a lump during a smear test, and it had ‘begun catching on her clothes’.
41. Our GP adviser confirmed it appears the Practice correctly assessed Mrs X’s symptoms and clinical history in line with GMC guidelines. Having done so, it appears the lump on her vulva did not have the typical appearance or associated symptoms of a VIN. As such, we do not feel it reasonably missed an opportunity to diagnose this in the appointment.
42. NHS Health A to Z guidelines explain skin tags are ‘usually harmless’ and ‘do not need to be removed’ unless they are causing problems. On this basis, our GP adviser confirmed they would not expect the GP to place an urgent referral to the dermatologist. It was appropriate to put a routine referral in place for Mrs X based on the diagnosis of a skin tag. Taking all this into account, we have seen no indications of failings for this part of the complaint.
Waiting times at the Trust
43. Mrs X explained the Practice sent her referral to gynaecology on 14 July 2023. She received a letter from it saying she would hear about an appointment by September 2023.
44. In October 2023 she had still not heard from the Trust so she contacted it. It explained the waiting list was very long, however she was still on it.
45. In December 2023 Mrs X contacted the Trust again. She was again told she was on the waiting list for an appointment.
46. Mrs X decided to get a private gynaecology appointment due to the waiting time. Following this, she decided to have the lump removed privately. This left Mrs X feeling like the Trust’s waiting time was unacceptable. She explains it caused her significant worry, and the lump grew which made it more painful.
47. Mrs X had her first appointment at the Trust in March 2024. This means she waited approximately eight months from the date of her first referral.
48. Our principles of good administration explain organisations have a responsibility to provide ‘effective services’ they should ‘plan their resources’ and ‘treat people equally and impartially’ to ‘ensure equal access to services and treatment’.
49. It is important to explain all NHS resources are subject to limitations. When we considered this complaint, we carefully looked at the demands on the Trust’s gynaecology service at the time of Mrs X’s treatment. We then considered if the Trust’s delays were unavoidable during the period in question. In line with our principles, we considered whether Mrs X was treated equally and fairly and waited an appropriate amount of time, in line with the demands on its service.
50. The Trust’s website explains wait times for its gynaecology department are around 16 weeks for an initial appointment. It also explains that this wait time is subject to change based on the demands of the service at that particular time.
51. We asked the Trust if it kept any records of the demands on their gynaecology service in July 2023 to March 2024. It explained ] it does not have an exact record of the waiting time for each specific month. However, it confirmed the appointment list for April 2024, included referrals from April 2023. This means the waiting list for appointments at the time of Mrs X’s referral was around 12 months long.
52. Mrs X’s initial appointment at the Trust was in March 2024. This was around 8 months after her referral from the Practice.
53. We recognise Mrs X was advised she would hear about an appointment in September 2023. We understand it will have been frustrating for her to not hear about her appointment when she expected to. We are sorry to hear of the added worry and uncertainty this caused, at what was already a difficult time.
54. The information provided by the Trust indicates the demand on the gynaecology department was high during this period . We are satisfied the Trust offered Mrs X an appointment within its timescale at the time and when it had capacity to do so. We did not identify any administration errors, which caused avoidable delays in her accessing an appointment. For this reason, we decided to take no further action regarding this complaint.